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Medical Aspects of Chemical Warfare

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Medical Aspects of Chemical Warfare Medical Diagnostics Chapter 22 MEDICAL DIAGNOSTICS † ‡ § BENEDICT R. CAPACIO, PHD*; J. RICHARD SMITH ; RICHARD K. GORDON, PHD ; JULIAN R. HAIGH, PHD ; JOHN ¥ ¶ R. BARR, PHD ; AND GENNADY E. PLATOFF JR, PHD INTRODUCTION NERVE AGENTS SULFUR MUSTARD LEWISITE CYANIDE PHOSGENE 3-QUINUCLIDINYL BENZILATE SAMPLE CONSIDERATIONS Summary * Chief, Medical Diagnostic and Chemical Branch, Analytical Toxicology Division, US Army Medical Research Institute of Chemical Defense, 3100 Rickets Point Road, Aberdeen Proving Ground, Maryland 21010-5400 † Chemist, Medical Diagnostic and Chemical Branch, Analytical Toxicology Division, US Army Medical Research Institute of Chemical Defense, 3100 Rickets Point Road, Aberdeen Proving Ground, Maryland 21010-5400 ‡ Chief, Department of Biochemical Pharmacology, Biochemistry Division, Walter Reed Army Institute of Research, 503 Robert Grant Road, Silver Spring, Maryland 20910-7500 § Research Scientist, Department of Biochemical Pharmacology, Biochemistry Division, Walter Reed Army Institute of Research, 503 Robert Grant Road, Silver Spring, Maryland 20910-7500 ¥ Lead Research Chemist, Centers for Disease Control and Prevention, 4770 Buford Highway, Mailstop F47, Atlanta, Georgia 30341 ¶ Colonel, US Army (Retired); Scientific Advisor, Office of Biodefense Research, National Institute of Allergies and Infectious Disease, National Institutes of Health, 6610 Rockledge Drive, Room 4069, Bethesda, Maryland 20892-6612 691 Medical Aspects of Chemical Warfare INTRODUCTION In the past, issues associated with chemical war- an exposed individual may be considered as a potential fare agents, including developing and implementing matrix (eg, blister fluid from sulfur mustard [North medical countermeasures, field detection, verifica- Atlantic Treaty Organization (NATO) designation: tion of human exposures, triage, and treatment, have HD] vesication). Regardless, analyses of these types of primarily been a concern of the military community samples are inherently difficult because of the matrix’s because most prior experience with chemical war- complex composition and the presence of analyte in fare agents was limited to the battlefield. However, trace quantities. chemical agents have been increasingly employed Noninvasive urine collection does not require highly against civilian populations, such as in Iraqi attacks trained medical personnel or specialized equipment. against the Kurds and the attacks organized by the Although biomarkers present in urine are usually short- Aum Shinrikyo cult in Matsumoto City and the Tokyo lived (hours to days) metabolites, they can be present subway. The attacks on the World Trade Center in in relatively high concentrations in samples obtained New York City and the Pentagon in Washington, DC, shortly after exposure. The collection of blood/plasma in 2001 have increased concern about the potential should be performed by trained medical personnel. large-scale use of chemical warfare agents in a civilian Blood/plasma samples offer potential benefits because sector. Incidents involving large numbers of civilians both metabolites and the more long-lived adducts of a have shown that to facilitate appropriate treatment, it macromolecular target can be assayed. The effective- is critical to identify not only those exposed, but those ness of using tissue to verify chemical agent exposure is who have not been exposed, as well. In addition to generally limited to postmortem sampling. For example, health issues associated with exposure, the political formalin-fixed brain tissues from fatalities of the Tokyo and legal ramifications of a chemical warfare attack subway attack were successfully used to verify sarin can be enormous. It is therefore essential that testing (NATO designation: GB) as the agent employed in that for exposure be accurate, sensitive, and rapid. attack.1 Other tissue samples can be obtained from the For the most part, monitoring for the presence of carcasses of animals at the incident site. chemical warfare agents in humans, or “biomonitor- Methods that do not directly analyze cholinesterase ing,” involves examining specimens to determine if (ChE) activity typically involve detection systems like an exposure has occurred. Assays that provide de- mass spectrometry (MS) combined with either gas finitive evidence of agent exposure commonly target chromatography (GC) or liquid chromatography (LC) metabolites, such as hydrolysis products and adducts to separate the analyte from other matrix components. formed following binding to biomolecular entities. MS detection methods are based upon specific and Unlike drug efficacy studies in which blood/plasma characteristic fragmentation patterns of the parent levels usually focus on the parent compounds, assay molecule, making MS detection desirable because it techniques for verifying chemical agent exposure identifies the analyte fairly reliably. Other detection rarely target the intact agent because of its limited systems, such as nitrogen-phosphorus detection and longevity in vivo. Following exposure, many agents flame photometric detection, have also been used. are rapidly converted and appear in the blood as hy- Some analytes can be directly assessed, whereas others drolysis products (resulting from reactions with water) may require chemical modification (eg, derivatization) and are excreted in urine. Because of rapid formation to enhance detection or make them more volatile in and subsequent urinary excretion, the use of these GC separations. More sophisticated techniques may products as markers provides a limited window of op- employ GC or LC with tandem MS (MS-MS) detection portunity to collect a sample with measurable product. systems, allowing more sensitivity and selectivity. More long-lived markers tend to be those that result Validating the performance of an analytical tech- from agent interactions with large-molecular–weight nique subsequent to initial in-vitro method develop- targets, such as proteins and DNA. These result from ment is usually accomplished with in-vivo animal covalent binding of the agent or agent moiety to form exposure models. Additional information may be macromolecular adducts. As such, the protein acts as gleaned from archived human samples from past a depot for the adducted agent and the residence time exposure incidents. Samples from humans exposed to is similar to the half-life of the target molecule. sulfur mustard during the Iran-Iraq War and a limited Blood/blood components, urine, and, in rare in- number of samples from the Japanese nerve agent at- stances, tissue specimens, termed “sample matrices” or tacks have been used to evaluate assay techniques. In “biomedical samples,” can be used to verify chemical the case of some agents, background marker levels are agent exposure. However, any sample obtained from known to exist in nonexposed individuals, making it 692 Medical Diagnostics difficult to interpret the results of potential incidents. Preexposure treatments or tests to monitor potential Therefore, in addition to assessing performance in ani- chemical agent exposure may be warranted for military mal models and archived human samples, it is essential personnel and first responders who must enter or oper- to determine potential background levels and inci- ate in chemically contaminated environments. How- dence of markers in nonexposed human populations. ever, laboratory testing may not be as useful for large It should be stressed that, for the purpose of exposure civilian populations unless there is a clear impending verification, results from laboratory testing must be chemical threat. At the same time, determining the considered along with other information, such as the health effects of chemical exposure is complex because presentation of symptoms consistent with the agent in it can affect the nervous system, respiratory tract, skin, question and results from environmental testing. eyes, and mucous membranes, as well as the gastroin- In the late 1980s the US Army Medical Research testinal, cardiovascular, endocrine, and reproductive Institute of Chemical Defense was tasked by the De- systems. Individual susceptibility, preexisting medical partment of Defense to develop methods that could conditions, and age may also contribute to the severity confirm potential chemical warfare agent exposure. of a chemically related illness. Chronic exposures, even The US Army Medical Research Institute of Chemi- at low concentrations, are another concern. In addition cal Defense had previously published procedures for to development of diagnostic technologies, strategies verifying exposure to nerve agents and sulfur mustard. to detect chemical agent exposure have become a These methods primarily focused on GC-MS analysis public health issue. of hydrolysis products excreted in the urine following The transition of laboratory-based analytical tech- exposure to chemical warfare agents. Subsequently, the niques to a far-forward field setting can generate methods using urine or blood samples were compiled valuable information for military or civilian clinicians. as part of Technical Bulletin Medical 296, titled “Assay In this transition, problems such as data analysis, Techniques for Detection of Exposure to Sulfur Mus- interpreting complex spectra, and instrument trouble- tard, Cholinesterase Inhibitors, Sarin, Soman, GF, and shooting and repair may need addressing. As analyti- Cyanide.”2 The publication was intended to provide cal methods are developed, refined, and sent farther clinicians with laboratory
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